Opinion: Lupus No Longer Seen As Complete Contraindication to Oral Contraceptive Use

by Denise Mann Kleinman

BALTIMORE, Maryland — Clinicians have increasingly prescribed oral contraceptives (OOs) for women with inactive or stable systemic lupus erythematosus (SLE), a dramatic change from former assumptions about OCs in this population, according to Michelle Petri, MD, a rheumatologist at Johns Hopkins University School of Medicine in Baltimore, Maryland and Jill P. Buyon, MD, a rheumatologist at the New York Hospital for Joint Diseases in New York City.

“Should oral contraceptives be prescribed in SLE? In the last five years, we have come a long way,” they write in a recent issue of Lupus (2008;17:708-710). “The answer today is frequently ‘yes’, whereas before, the answer was almost always never.”

Why the change of heart?

Drs. Petri and Buyon reviewed biochemical data, animal data, human case control data and human cohort studies as well as randomized double-blind placebo-controlled trials including the Safety of Estrogen in Lupus: National Assessment (SELENA), the SELENA oral contraceptive pill trial, to come to their conclusions about the use of birth control pills in women with lupus.

According to results from SELENA, women who have inactive or stable active SLE could be offered oral contraceptives if they are not prescribed for more than a month following diagnosis. Other exclusion criteria highlighted in this trial included:

Diastolic pressure greater than 95 mmHg or systolic pressure greater than 145 mmHg on three readings

History of spontaneous deep venous thrombylosis

Arterial thrombosis or pulmonary embolus

Presence of IgG, IgM or IgA anticardiolipin antibodies and or demonstration of lupus anticoagulant by the dilute Russell viper venom test

History of gynecologic or breast cancer

History of heart attack

Liver dysfunction or liver tumors

Uncontrolled diabetes

Congenital high cholesterol

Migraines with neurologic symptoms

Unexplained vaginal bleeding

Positive pregnancy test

The SELENA trial, however, was not generalizible to all women with SLE due to the rather extensive exclusion criteria. In the SELENA oral contraceptive trial, oral contraceptive use was similar to placebo in terms of disease flares.

“Should oral contraceptives be prescribed in SLE? In the last five years we have come a long way.The answer today is frequently ‘yes,’ whereas before, the answer was almost always never.” – Michelle Petri, MD

The bottom line? “The risks of OCPs should always be discussed and documented,” they write. “Oral contraceptives cannot be prescribed to all SLE women, but when appropriate may demonstrably improve quality of life.”